THE final Rail Accident Investigation Branch report into the deaths of two Network Rail track workers at Margam in South Wales in July last year has made eleven recommendations.
The two men were hit by an express train, and a third who was with them had a narrow escape.
Earlier reports had already revealed that a lack of lookouts protecting the work site was the main cause, along with the strong likelihood that all three men were wearing ear defenders because one of them was using a noisy power tool.
They were also ‘carrying out a maintenance activity which they did not know to be unnecessary,’ according to the latest report.
The controller of site safety had proposed a safe system of work but this was not adopted. The report finds that ‘the alternative arrangements became progressively less safe as the work proceeded that morning and created conditions that made an accident much more likely’.
The RAIB’s investigation found ‘several factors which led to this situation, relating to the work itself, the way the safe system of work was planned and authorised, the way in which the plan was implemented on site, and the lack of effective challenge by colleagues on site when the safety of the system of work deteriorated’.
The investigation has also considered ‘why Network Rail had not created the conditions that were needed to achieve a significant and sustained improvement in track worker safety’. One of four factors was that ‘Network Rail’s safety management assurance system was not effective in identifying the full extent of procedural non-compliance and unsafe working practices’, and another was that ‘Network Rail had focused on technological solutions and new planning processes, but had not adequately taken account of the variety of human and organisational factors that can affect working practices’.
Nine of the report’s 11 recommendations are addressed to Network Rail.
Chief inspector of rail accidents Simon French said: ‘The death of the two track workers who were struck and killed by a train at Margam was a tragic loss for their families and friends. It has also had a profound effect on all of us at RAIB, and those who died and all those who were close to them, are in our thoughts. The railway is like a family, with a distinct culture all its own, and we all feel deeply the loss of colleagues.
‘This accident has reinforced the need to find better ways to enable the safe maintenance of the railway infrastructure. The areas that need to be addressed to improve the safety of track workers have been repeatedly highlighted by 44 investigations carried out by RAIB over the last 14 years. The most obvious need is for smart and accurate planning to reduce the frequency with which trains and workers come into close proximity, while also meeting the need for access to assets on an increasingly busy railway system.
‘I believe it is essential that Network Rail addresses the fundamental requirements that have been highlighted by RAIB’s investigations over the years. These include: developing leadership skills and involvement of the site team in the planning process, including the identification of site hazards and the local management of risk; better management of people who work on the track, including supervision and assurance, that will make sure correct working practices are in use, and to identify areas for improvement; greater use of technology to control access to the infrastructure, to provide warnings of approaching trains or to protect possession limits.‘
He added that the railway ‘has a lot to do to cultivate and support a generation of leaders who are able to make a real difference to track safety. In recent years the industry has launched projects intended to achieve this, but they have not always been successful. It is frustrating that the railway has been unable to carry people with it in its attempts to bring about real change.
‘I remain hopeful that the rail industry will find a way to address these thorny and persistent issues. There is now a real sense that things must change. We’ve come a long way since the days when fatal accidents involving track workers were commonplace. However, it’s now time for some clear thinking on how best to further reduce the risk.’
RMT general secretary Mick Cash said: ‘The report is comprehensive and raises many issues of concern relating to industry standards, processes and arrangements and supports many of the concerns on track worker safety that RMT has been raising for many years. All parties in the industry need to reflect on the implications of the report and strive to put track safety as a top priority and make the necessary changes with the aim of eliminating fatalities and serious injuries.
‘RMT will continue to engage with Network Rail, the rail companies and the authorities on issues arising from the report and will be pushing for the highest track safety standards possible in order to protect our members.’
Network Rail has yet to respond.